India does not need an enemy

The Delhi CM Arvind Kejriwal intends to set up a three tier public health care system in the country’s capital. A 1000 Aam Aadmi Mohalla Clinics will be the primary health care centres. A 100 polyclinics will function as a link between the primary and main health centres. This system will reduce the rush in OPDs of hospitals. In Sri Lanka there is a health centre within 1.4 km from the residence of most people. Life expectancy in Sri Lanka at about 75 years is ten times more than in India. Infant mortality rate in Sri Lanka is merely 11 per thousand live births compared to 47 in India. Under-five mortality rates in India and Sri Lanka are 61 and 12, respectively, for the same number of live births. Maternal mortality ratio per lakh live births in India is 200, whereas in Sri Lanka it is merely 35. Infant immunization in Sri Lanka is almost universal whereas India struggles to reach out to less than three fourths of its children.
Proportion of underweight children in India is shockingly high at 43% whereas Sri Lanka has managed to keep it at 21%. Health care centres nearer one’s home and greater public health spending must have contributed to the better than South Asian and World health care averages for Sri Lanka. Sri Lanka spends $203 per person per year on health care whereas India spends merely $39. India has the worst child nutrition indicators in the world. 43% of its children under five years of age have weight less than normal for their age and 48% have height less than normal for their age. 28% of infants are born underweight in India. These figures are worse than the South Asian and world averages.

In spite of such poor nutrition record the Union Health Ministry has decided to close down the National Nutrition Monitoring Bureau which used to keep a watch on the nutritional status of socially vulnerable groups, the only organization of its kind functioning in the country. It is unclear how the government now plans to keep a check on the situation of malnourishment. Obviously, the problem is not going to be solved by pushing it under the carpet. First there has to be recognition of the fact and then attempt to find a remedy. A recent report released in November 2015 by John Hopkins Bloomberg School of Public Health has again shamed India where maximum number of children die of preventable causes - diarrhoea and pneumonia - globally.

India spends merely about 1% of its GDP on public health care whereas most other middle-income countries spend more than 2-3% and most of high-income countries spend more than 8%. The BRICS countries other than India spend 3-8% of their GDP on public health. The world average is 6.5%. The UPA government had promised an increase upto 2-3% in 2004 as part of its common minimum programme, however it never fulfilled its promise. According to the Narendra Modi government’s own National Health Policy 2015 Draft, “global evidence shows that unless a country spends at least 4-5% of its GDP on public health, basic health care needs are seldom met”. In spite of these facts the Modi government is reducing the health budget not just in percentage but in absolute terms. This will have far reaching implications for the nation including epidemics. This government spends too much time in worrying about nation’s security but doesn’t care about the security of its citizens. How can a nation with half its children malnourished and half its women anemic be strong? The child population of under five years of age that dies every year in India is more than two times the number of people who died in Hiroshima and Nagasaki nuclear bombing. India doesn’t need an enemy!

The government is pushing the health sector towards privatization where corruption is the norm. With government’s major thrust on public private partnership (PPP), over-burdened public healthcare system is getting further jeopardized, making healthcare inaccessible to those most in need and most marginalized. Government doctors, in spite of a ban, are keen to see patients in private. There is a nexus of doctors, pathological laboratories and medicine companies. Surgeries, for example, delivery with a Caesarean, are performed where none is needed. Patients referred from District hospitals to State government hospitals end up in private clinics thanks to dubious private ambulance services. Because of the information asymmetry the patient is totally at the mercy of doctors. If the patient is unable to pay after treatment s(he) can be held hostage.

The national health insurance scheme legally allows private practitioners to make money off poor patients. The insurance premium of Rs. 30,000 paid for by the government for treatment at an accredited private hospital or clinic often gets over in one or a few visits because of exaggerated bills. Now the UP Health System Strengthening Programme is going to engage private laboratories to perform pathological tests for 40 district hospitals which will be paid for by the government. Thus most of the subsidy in the name of poor actually ends up as profits for private companies.

On the occasion of foundation stone laying ceremony of Medanta hospital in Lucknow, its head Dr. Naresh Trehan committed to make UP a TB-free state. It is a clear case of government withdrawing from its role of welfare state and private players moving in to fill the vacuum. But one cannot ignore the fact the private players are there only so long as profits are to be made. Not very long back a private hospital by the name of Fordd in Lucknow switched off the ventilator of a patient who was unable to pay an additional amount of Rs. 10,000. The patient, who had already paid Rs. 4.6 lakhs till that time, was left to die. Private hospitals certainly cannot take on the role of state. In most of the world where quality health care services are available it is the government which has provided for. Private cannot substitute the public. We must stop believing the illusion that privatized system of health care is better. There is a need to believe in the government system and to make it accountable to the people.

A bright spot in India’s otherwise dismal health care sector has been its decades-old policy to promote generic medicine manufacturing industry with the aim of supplying affordable essential drugs both domestically and globally. As a result today India is one of the largest producers and exporters of generic medicines and is proudly called “Third World’s Pharmacy”. People of low income countries rely critically on India for medicines for diseases such as AIDS, tuberculosis and malaria at prices as low as 1% of patented medicines. There is a threat that in order to please the USA government and multinational pharmaceutical companies, the Indian government might change its IPR law to make it difficult for its generics producers to export to Africa and other third world nations. Simultaneously the Indian government is allowing multinational pharma firms to strike deals with Indian firms to manufacture their patented drugs and sell at prices lower than in high-income countries but much higher than what would be generics’ prices. This is yet another indication of Modi government’s dilution of commitment to public health.

As the editor-in-chief of a leading medical journal Lancet recently said, health has completely vanished from policy agenda since PM Modi has come in, and India is on the edge. Before this government public health was at least on the agenda even though it was not accorded the priority it deserved. For the sake of its population’s wellbeing as well as sustaining its economy, the only option India has is to put citizens’ health at the forefront of political agenda, drastically increase investment in public health systems and regulate private sector to supply affordable generic drugs and healthcare services.